Private Health Insurance Decision Reference 2023-0079

• Case Outcome: Rejected
• Subject Matter: Private Health Insurance
• Reference: 2023-0079
• Date: 31 March 2023
• Finantial Sector: Insurance
• Conducts Complained Of: Claim handling delays or issues,Rejection of claim – partial rejection

Decision Ref:

2023-0079

Sector:

Insurance

Product / Service:

Private Health Insurance

Conduct(s) complained of:

Claim handling delays or issues

Rejection of claim – partial rejection

Outcome:

Rejected

LEGALLY BINDING DECISION OF THE FINANCIAL SERVICES AND PENSIONS OMBUDSMAN

The Complainant held a Health Insurance Policy with the Provider. The policy period in

which this complaint falls, is from 1 January 2019 to 31 December 2019. The complaint

concerns the Provider’s assessment of benefit payable under the policy, in respect of the

cost of medical treatment the Complainant’s son received in the UK, in October 2019.

The Complainant’s Case

The Complainant says her son, who is an insured person on her Health Insurance Policy with

the Provider, “has an unusual condition” and that as part of the investigation of this

condition, one of his treating physicians in Ireland advised that he “have a muscle biopsy in

[a named hospital in the UK] as they have equipment that is not available anywhere else in

the UK or Ireland”. The Complainant says another of her son’s treating physicians in Ireland

“verified that this level of testing was not available in Ireland”.

The Complainant sets out her complaint in the Complaint Form she completed, as follows:

“A muscle biopsy is done in the full hospital setting and done in theatre and involves

the thigh muscle being cut open and a section of muscle is taken for analysis. It is

done under full surgical protocol.

I had contacted [the Provider] to tell them [my son] was having this surgery and

wanted to claim under the medical tourism benefit … This benefit is payable up to a

maximum of €100,000, subject to preauthorisation, for medically necessary surgical

procedures in the EU. The level of benefit will be limited to the maximum level of

cover that your plan allows or a lesser amount if the overseas cost is less.